12 things you should know about pain relievers

Remember when it was so simple? Take two aspirin, call the doctor in the morning. Now we’ve got a staggering number of pain relievers to choose from. Picking the right one is enough to give you a headache! So here are a few pointers to help you navigate the pain reliever aisle.

1. Tylenol can cause liver damage. The active ingredient in Tylenol is acetaminophen. Acetaminophen overdoses, half of them unintentional, are now the leading cause of acute liver failure in the United States. Four grams per day (about 12 regular-strength Tylenol tablets) is considered the safe upper limit, but that might be too much for some. Large doses are the main risk, but there are reports of people developing liver problems after taking small to moderate amounts of acetaminophen for long periods of time.

People who drink alcohol regularly or have a less than healthy liver are more vulnerable to acetaminophen’s toxic effects, so the safety threshold for them is lower. Exactly how much lower is difficult to say, but some experts say that to be on the safe side, heavy drinkers shouldn’t take more than 2 grams daily.

Acetaminophen is an ingredient in many over-the-counter cold and headache medications. Some people may be taking more of the drug than they realize because of these “hidden sources.”

2. If it’s about NSAIDs, it doesn’t apply to acetaminophen. Most of the pain relievers that we’re familiar with, like ibuprofen and naproxen, and some that aren’t so familiar, like diclofenac (Cataflam, Voltaren), are nonsteroidal anti-inflammatory drugs (NSAIDs). Acetaminophen is not an NSAID. It is not anti-inflammatory and relieves pain in other ways.

3. All the NSAIDs may increase heart attack risk. NSAIDs revolutionized the treatment of pain but have the drawback of being hard on the stomach; in extreme cases, they cause gastrointestinal bleeding.

The COX-2 inhibitors were supposed to be the better NSAIDs: a new generation of medications that would relieve pain but spare the gut. Of course, it hasn’t worked out that way. Vioxx was yanked from the market in 2004 after it was linked to an increased risk for heart attacks. Bextra came off the market a few months after Vioxx because of possible cardiovascular effects and a link to a potentially fatal skin disease.

Soon all the NSAIDs fell under a cloud of suspicion — and it’s still there. Finnish researchers reported in 2006 that use of all NSAIDs — even the traditional ones — increased the user’s risk of having a heart attack.

4. Naproxen may be the safest one for the heart. Studies have concluded that naproxen doesn’t increase heart attack risk. Although the Finnish study didn’t give it a clean bill of health, of all the NSAIDs, naproxen increased heart attack risk the least.

5. Low doses of Celebrex seem to be safe. After the bad news about Vioxx and Bextra, the future of all the COX-2 drugs was in doubt. But Celebrex has stayed on the market, and at doses of 200 mg per day or less, doesn’t seem to make a heart attack any more likely. (We’re hedging our bets a little because study results haven’t been uniformly positive.)

6. You can take something to help with the stomach woes. If NSAIDs bother your stomach or you’re at high risk for gastrointestinal complications, taking a proton pump inhibitor like omeprazole (Prilosec) or lansoprazole (Prevacid) can help. Taking one of these offsets the side effect.

7. Take your daily aspirin before ibuprofen or naproxen. Small daily doses of aspirin (the standard amount is 81 mg) make platelets less “sticky,” which reduces the chances of the formation of a blood clot in an artery that supplies the heart or brain. Aspirin has this anti-adhesive effect because it gloms on to an enzyme called cyclooxygenase. Ibuprofen and naproxen also seek out cyclooxygenase. If they get there first, there’s no room for aspirin.

The FDA recommends that when you take aspirin for cardiovascular protection, you should wait at least 30 minutes before taking ibuprofen. Alternatively, you can take an aspirin eight hours after taking ibuprofen. The FDA recommendation doesn’t include naproxen, but studies have shown that naproxen can also ace out aspirin for a spot on the cyclooxygenase enzyme.

8. Beware of blood pressure increases. The NSAIDs, including the COX-2 drugs, tend to boost blood pressure. The effect is strongest and happens more consistently in people who have high blood pressure already and are taking medication to control it, but there’s evidence that people with normal blood pressure are also affected. Acetaminophen, in high doses and among women, has also been shown to cause small hikes in blood pressure.

9. Don’t go cold turkey. If you take an NSAID regularly, don’t stop suddenly. Sudden withdrawal makes blood clots more likely to form.

10. Beware of kidney woes. NSAIDs, including the COX-2 drugs, can be hard on the kidneys and, in extreme cases, cause kidney failure.

11. The dose matters. Many of the risks associated with pain relievers emerge only after long-term or heavy use. You shouldn’t be scared about taking the occasional Advil or Aleve for a headache or aches and pains.

12. Your genes matter. There is a lot of individual variation in how people react to pain relievers. It may take some trial and error to find the pill that works best for you.

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